
Submit a Referral
Referring patients is simple. Download our fillable PDF forms below, complete the required information, and submit to us—we'll handle everything from there.
Fax (562) 402-4629 or email info@mercyinfusion.com with the following:
Patient demographic sheet, Insurance card (front & back), Labs, chart notes, & relevant test results. We take care of the rest!
Referral Forms:
Gastroenterology
Neurology
Dermatology
Pulmonology
Rheumatology
Immune Globulin Autoimmune Disorder
Immune Globulin Maternal Fetal Medicine
Immune Globulin Primary Deficiency
Immune Globulin Transplant
Need a different form? We’re here to help!
If you would like to see a referral form that is not listed above, please let us know.
Providers – want to learn more?
Request a visit from a Mercy Infusion representative, and a member of our team will visit your office to discuss our services and see how we can best serve your patients